Practice team blog

Looking out of my window at the garden on a lovely sunny day reminds me of my Dad. He loved the summer, sitting in the back garden with my Mum.

I remember the last summer he was alive. His walking had deteriorated and his Parkinson’s and chest problems were catching up with him.

We got him out in the garden and he sat under the blackberry brambles catching the branches with the hook of his walking stick so my two boys could pick off the berries.

We were in t-shirts but he felt cold and was wearing a jumper, jacket and hat but I remember him looking up and saying how lovely it was to have the sun on his face. I knew then he probably didn’t have another summer, and I think he knew it too, but by then he had learnt to appreciate the small pleasures life offered.

Last night I was chatting to a friend who works in a nursing home and she said the biggest challenge this week will be ensuring everyone in the home stays hydrated. The drinking challenge is on.

It made me think about all those people confined to the inside of nursing homes or their own homes, unable to enjoy the benefits of a sunny day without the help of others. People who don’t get to feel the sun on their faces because there isn’t time to get them up and out.

By virtue of staffing levels and workload we often have our heads down dealing with the physical needs of the chronically sick and those with disability, and it is easy to forget that the simple things make a big difference.

It takes a bit of time and organisation but it is possible.

Yesterday, as my son and I walked to the shops to buy ice-creams, we passed a group of carers and people with learning disabilities doing the exact same thing.

We were all sharing the same pleasure and anticipation that an unexpected sunny evening brings, and if we need a clinical focus for this blog, we were topping up our vitamin D levels at the same time.

News that a West Midlands trust is to extend a scheme whereby unemployed people deliver patient care makes me deeply uncomfortable.

First there is the issue of whether it is right to be asking jobseekers to spend eight weeks doing unpaid work in an NHS that is shedding staff. I appreciate that many unemployed people need support in their search for work, and being able to show relevant work experience can make all the difference to job applications.

While Sandwell and West Birmingham Hospitals Trust may not be using unpaid workers to undertake work previously done by paid staff, there is certainly the possibility for trusts to consider this as a way of filling gaps left when staff numbers are cut.

I also have misgivings about the type of work the jobseekers are being allocated. While many of the tasks are uncontroversial - general tidying, welcoming visitors, running errands, and reading to patients – they are also being asked to serve drinks to patients and assist with feeding.

Ensuring patients receive adequate nutrition and fluid is a fundamental nursing role, and in the reports highlighting poor standards of care over the past couple of years, nurses have been repeatedly accused of failing their patients in this respect.

The profession has been accused of being more interested in academic qualifications than in core nursing responsibilities, yet fluid and nutrition are suddenly the domain of those undertaking unpaid work experience.

Hiving off these important responsibilities devalues nurses’ skills and puts patients at risk, yet nurses will still be held accountable if anything goes wrong, because they will be delegating the tasks to the unpaid workers.

Nursing has come in for a huge amount of flak recently, and the poor practice of the few has been used as a stick to beat the many. How is the profession ever to put its house in order if it is bombarded with mixed messages about its key responsibilities?

Falling district nurse numbers, social care cuts, and an ever growing number of increasingly complex patients. It’s a frightening mix and with a significant number of district nurses set to retire in the coming decade, it’s hard to see that others will be rushing to step into their shoes.

It’s already a tough job without all the increasing pressure currently being loaded on. Working in a ‘hospital without walls’ is a challenging role. Making decisions about frail and elderly patients with multiple co-morbidities in their own home takes skill and training. There is no second opinion readily at hand – you are on your own with limited resources. While nursing support workers do a great job in working alongside registered nurses in the community, the complexity of the work means that the ratio of registered nurses and support workers must not swing too far in the wrong direction.

The push to increase the numbers of health visitors is welcome. However this campaign is more likely to recruit from the community nurse workforce as those already working in the community are more likely to apply. For those working in hospitals, it can be a leap of faith to take that step to work outside the hospital environment that they are used to.

Also the increase in health visitor numbers must not be used as a panacea for the fall in district nursing numbers. I was struck by how Andrew Lansley answered a question about declining nos of district nurses at RCN Congress by talking about the increasing number of HVs. A good initiative but it’s not the same thing.

The RCN report makes clear for the urgent need for more district nurse numbers and support for this crucial arm of the profession. Lack of support and care of patients in the community will inevitably lead to more hospital admissions. It feels like we are just going around in circles. Policy makers need to wake up to the fact that all the money comes out of the same pot so cuts in the community will lead to increased costs in hospitals.

Along with “What biology coursework is now on You Tube?” and “How can you revise when your physics book is downstairs?” Sadly my daily lecture on the benefits of a plan, to-do lists, colour pens and PostIt notes is greeted with, at best, rolling eyes and a “whatever”.

The ongoing debate about revision plans reminded me of the debate in nursing about the value of documentation.

Is it possible to start work without a plan of what you are going to do? Yet a news story last week highlighted the enormous amount of work nurses have to leave undone because of staffing levels.

One of the tasks frequently omitted was the planning and documentation of care: 47% said they failed to develop or update care plans; 33% failed to adequately document care; and 28% failed to complete care plans.

The test of a good care plan is that staff, at a glance, can identify what has been done before, if it was successful and what is planned for the future. I remember working with a ward sister who advised staff to read the care plan first and then ask questions. She believed a good care plan should save time rather than make work.

Yet many of us have a dysfunctional relationship with documentation. It is viewed as an add-on, often completed after the work is finished in the office over a cup of coffee. The quality and quantity of paperwork is a barrier to completing it and incomplete documents have little practical value for day-to-day work, so no one looks at them or trusts the content. Sadly the value of good documentation is often only realised when records are used as evidence in court.

I would argue that a patient’s written care plan is pivotal to providing personalised care and there needs to be a radical rethink of how this happens in practice.

Clinical staff must be involved in the design and content of documents so they are clinically useful. The temptation to add in another assessment or tick list to meet a new directive or target needs to be carefully considered.

Nursing documents should be owned by individual patients and the nurses caring for them. They should be dynamic description of patients’ wants and needs, how these can best be addressed and the progress patients are making. If this is the focus, nursing documentation will become a valuable and essential part of care. But if this is to happen, the most important requirement is that time is made available and staff are supported to ensure this essential part of care is completed.

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